as amended, Gomez.
begin deleteAudits of pharmacy benefits. end delete
Existing law imposes specified requirements on an audit of pharmacy services provided to beneficiaries of a health benefit plan. Existing law provides that those requirements do not apply to an audit conducted because a pharmacy benefit manager, carrier, health benefit plan sponsor, or other 3rd-party payer has indications that support a reasonable suspicion that criminal wrongdoing, willful misrepresentation, fraud, or abuse has occurred, or to an audit conducted by, or at the direction of, the California State Board of Pharmacy, the State Department of Health Care Services, the State Department of Public Health, or the Medicare program.end delete
This bill would make nonsubstantive changes to that provision.end delete
Vote: majority. Appropriation: no. Fiscal committee: no. State-mandated local program: no.
The people of the State of California do enact as follows:
For purposes of this chapter, the following definitions
5(a) “Carrier” means a health care service plan, as defined in
6Section 1345 of the Health and Safety Code, or a health insurer
7that issues policies of health insurance, as defined in Section 106
8of the Insurance Code.
9(b) “Clerical or recordkeeping error” includes a typographical
10error, scrivener’s error, or computer error in a required document
12(c) “Extrapolation” means the practice of inferring a frequency
13or dollar amount of overpayments, underpayments, nonvalid
14claims, or other errors on any portion of claims submitted, based
15on the frequency or dollar amount of overpayments,
16 underpayments, nonvalid claims, or other errors actually measured
17in a sample of claims.
18(d) “Health benefit plan” means any plan or program that
19provides, arranges, pays for, or reimburses the cost of health
20benefits. “Health benefit plan” includes, but is not limited to, a
21health care service plan contract issued by a health care service
P3 1plan, as defined in Section 1345 of the Health and Safety Code,
2and a policy of health insurance, as defined in Section 106 of the
3Insurance Code, issued by a health insurer.
14 “Pharmacy” has the same meaning as provided in Section
17 “Pharmacy audit” means an audit, either onsite or remotely,
18of any records of a pharmacy conducted by or on behalf of a carrier
19or a pharmacy benefits manager, or a representative thereof, for
20prescription drugs that were dispensed by that pharmacy to
21beneficiaries of a health benefit plan pursuant to a contract with
22the health benefit plan or the issuer or administrator thereof.
23“Pharmacy audit” does not include a concurrent review or desk
24audit that occurs within three business days of transmission of a
25claim, or a concurrent review or desk audit where no chargeback
26or recoupment is demanded.
28 “Pharmacy benefit manager” means a person, business, or
29 other entity that, pursuant to a contract or under an employment
30relationship with a carrier, health benefit plan sponsor, or other
31third-party payer, either directly or through an intermediary,
32manages the prescription drug coverage provided by the carrier,
33plan sponsor, or other third-party payer, including, but not limited
34to, the processing and payment of claims for prescription drugs,
35the performance of drug utilization review, the processing of drug
36prior authorization requests, the adjudication of appeals or
37grievances related to prescription drug coverage, contracting with
38network pharmacies, and controlling the cost of covered
immediately following Section 4439
Section 4431 of the Business and Professions
33Code is amended to read:
(a) This chapter shall not apply to an audit conducted
35because a pharmacy benefit manager, carrier, health benefit plan
36sponsor, or other third-party payer has indications that support a
37reasonable suspicion that criminal wrongdoing, willful
38misrepresentation, fraud, or abuse has occurred.
not apply to an audit conducted by, or at
40the direction of, the California State Board of Pharmacy, the State
P6 1Department of Health Care Services, the State Department of
2Public Health, or the Medicare program.